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Published: November 22nd 2009
I feel compelled to share the very little I know about the state of healthcare in Cambodia. I want you all to read this because:
• You should never take for granted how good your own life is or lose sight of the inequity in the world;
• Some of you, as medical professionals, may have some good thoughts or ideas about appropriate responses; and
• Some of you might have an idea about fundraising and resources to address some basic needs.
Again, I want to emphasize that I know almost nothing about the Cambodian healthcare system, but some things I saw with my own eyes, some things I was told by people I trust, and some information comes from research by presumably trustworthy organizations. I had read many of the stats before, but no data can prepare you for the reality. This is my early stab at summarizing what I’ve seen.
Here are some facts and figures (with most sources listed at the end of this entry.) More interesting stuff follows, so stick around for that.
Infant Mortality rate
(deaths per 1000 live births):
• Cambodia: 66
• US: 6.3
Under age 5 mortality rate
(deaths per 1000 live births):
• Cambodia: 141
• US: 8
Maternal Mortality Rate
(deaths per 1000 live births):
• Cambodia: 461
• US: 14
Life expectancy:
• Cambodia: 58 years
• US: 79 years
Health expenditure per capita:
• Cambodia: $ 26
• US: $6096
Deaths among children under age 5 due to diarrheal disease:
• Cambodia: 16.6%!<(MISSING)br>• US: 0.1%!<(MISSING)br>
Deaths among children under age 5 due to pneumonia:
• Cambodia: 20.6%!<(MISSING)br>• US 1.3%!<(MISSING)br>
%!o(MISSING)f children under age 5 stunted for age:
• Cambodia: 43.7%!<(MISSING)br>• US: 3.3%!<(MISSING)br>
Population with sustainable access to improved drinking water:
• Cambodia: 33%!<(MISSING)br>• US: 99%!<(MISSING)br>
Population with sustainable access to sanitation facilities:
• Cambodia: 16%!<(MISSING)br>• US: 100%!<(MISSING)br>
Annual expenditure on
pet food in US and Europe, 1998:
$17 billion Annual cost of scaling-up vaccination, malaria prevention and essential treatment to each child in the developing world, 2001:
$7.5 billion (Source: World Health Organization)
Cambodia , where one in every seven children does not reach the age of five,
is sadly the only country in the region that has seen an increase in child mortality since 1990.
(Source:
A World Where Children Everywhere Live beyond the Age of Five)
Statistics are sometimes interesting, but rarely conjure up a vivid picture of what they truly mean. I have
some pictures, both literal and figurative, to share with you.
At one of the rural schools, we brought some basic first aid supplies and children were encouraged to come see us if they had a complaint. Over three visits, this is what we saw:
• 10-20 kids with pus draining from their ears. Antibiotic eardrops are available over the counter, and it seemed more likely that these were external ear infections (from swimming in contaminated water) rather than internal ear infections, so we cleaned ears with hydrogen peroxide and applied drops. There was no way to supply drops for the kids to take home, so we hoped for the best and saw a few kids more than once. By the third visit to the school, I saw fewer infected ears, but whether that’s because they improved or because they didn’t want to subject themselves to the treatment, I’ll never know.
• 20-30 kids with infected cuts, scrapes, burns, and abrasions, mostly on their feet and lower legs. Some kids had to soak their feet and get cleaned up before I could even see what we were dealing with. The burns were commonly on calves, where children accidentally came into
contact with hot motorcycle mufflers, which leave a burn the size of a child’s palm. We also saw burns on hands and one on the face, related to a cooking accident. We applied Betadine, peroxide, antibiotic cream, and/or hydrocortisone cream and bandaged them up with a variety of Band-Aids, gauze and tape in the hopes that it would keep the dirt out for a few hours.
• 5-6 kids with unidentified itchy rashes all over their lower extremities. Some of them had scratched themselves raw and had superficial skin infections. One theory is that this rash is caused by running through the rice paddies, which scratches up your legs and coats your skin with all kinds of irritants and bacteria (
e. coli, among others.) I had little to offer these kids except a bar of soap and instructions to wash daily.
• 2 little girls with infected ear piercings. (Nobody here gets their ears pierced at the mall, so they aren’t given a bottle of fancy disinfectant to clean with while earlobes heal.)
• Several kids with scabby or weeping abrasions on their scalps. Some children had had their heads shaved and some had not. Whether the abrasions were caused by
scratching (head lice are rampant) or by some other cause, I couldn’t tell you, but we dosed the infected-looking ones with antibiotics.
• One kid with a swollen foot and ankle, red and hot and puffy, too painful to stand on. He had a serious fever, and the pain was bad enough for him to flinch, which we never saw other kids do unless they were babies. (The babies cried if we even looked at them from a distance of less than ten feet.) Arrangements were made for him to go to the hospital the next day. (In other words, the PLF provided the family with money to
get to the hospital an hour away and explained the risks of the consequences if he didn’t go.) He went to the hospital, who apparently told the family it “wasn’t that bad” and they hadn’t needed to come, but they did give him some antibiotics and he was much improved a few days later.
Most, if not all, of these “minor” problems that we saw could have been prevented by basic hygiene or simple first aid supplies. But these children have no access to safe water or soap, don’t really understand
the concept of germs, and have compromised immune systems because of their inadequate nutrition. Any of us have had similar cuts or scrapes or mosquito bites (though maybe not so many muffler burns) that have healed uneventfully because we kept them clean and fought off potential infection. These kids are covered with scars from various infections and injuries, and I hate to think what might have happened to the boy we sent to the hospital if he hadn’t gone. I had visions of him becoming septic from the infection and dying within days, which was a real possibility. It happens to other children here every day. I’m still not sure if his family truly didn’t recognize the severity of the problem or didn’t have any resources to get to the hospital.
Some other things I witnessed:
We were lucky enough to visit the Children’s Development Village, an orphanage housing 44 children about an hour outside of Siem Reap. The children here are lucky enough to have adequate nutrition and regular healthcare, but the project coordinator shared with me her wish that they could be immunized against hepatitis, a common and serious problem. She explained that there are now
programs to cover immunization of newborns without cost, but children living at the CDV were not eligible due to their age. She thought that the cost for vaccine would be approximately $150 per child. (I’m assuming she was thinking of the combo vaccine.) Anyone know more about costs of this, or have access to a drug rep or group who would like to help provide this? I would happily return to administer vaccine, even if it meant staying for a long time to get the full series of vaccines finished!
The principal from the most remote PLF-sponsored school came the three hours to Siem Reap to bring a 17-year-old sixth grader to the hospital. The boy had been having pain all over for many weeks and it was persistent and severe enough in his legs that he couldn’t walk. (This was despite treatment from “Dr. Kim,” who is not a doctor at all, but some sort of medic who teaches at the school and probably provides the only health care that village gets.) The boy was admitted to the local provincial hospital. (If he had been under 15, he could have been admitted to one of the two foreign-run
children’s hospitals in town, where he would have had good quality care.) We went to see him there the next morning. He and his mother had sat on the tile floor all day and all night in the one of the wards. There were no beds available, and they had no sleeping mat. The boy had an IV hanging from a hinge on the wall. The hospital provides no food, and the boy’s mother had initially been too intimidated at being “in the city” to go outside and find out where to get something to eat with the money PLF provided. They had nothing to do, no change of clothes, nothing to make them comfortable, and no diagnosis. No one knew what the IV contained, and we learned that the culture forbids anyone from asking. (Ponheary couldn’t bring herself to ask, even with Lori’s instruction to do so.)
Interestingly, hospitals not only don’t promise you a bed nor provide food, it's quite typical for them to offer no medicine. Frequently the family is told which medication to go and buy at a pharmacy - which means if the family has no money in hand, then they get no medicine.
Hospital hallways
If you're fortunate (or unfortunate) enough to see oneWhether the correct medication is available (or safe, or unexpired) and whether the family truly understands what to get or how to take it after discharge is another true mystery.
Hospitals don’t always admit people just because they need IV treatment either. Often an IV is started and the patient sent away to return the next day. At least once, I saw someone riding on the back of a moto holding their IV bottle up over their head with their good arm. I doubt everyone returns to the hospital to have their IV removed. (IV tubing is also very handy for rigging up a cooling system for an overheating motorcycle engine. You can adjust the drip of water over the engine according to need.)
The ward the boy was in consisted of a few rooms and hallways holding metal bed frames. The beds had only straw mats over the springs, no mattresses, and the rooms didn’t have doors. Men and women shared rooms, meager belongings lying under the bed (along with the trash) or hanging in a plastic bag. People wore their own clothes, and had blankets if they had brought them themselves. Paint was peeling off the
walls, there were stains and puddles on the floors, and a general odor of latrine pervaded. Naked children wandered up and down the hall (where other patients also sat on the floor or on mats), presumably because their mother was hospitalized and they had nowhere else to be. The two-story hospital buildings surrounded a sorry-looking dirt and concrete courtyard where vendors sold snacks and patients and family members washed under a tin-roofed shelter.
I never saw anyone who looked as if they worked there.
The next day, the boy was sent home. Diagnosis: severe vitamin deficiency of some kind. Treatment: Dr Kim would inject him with vitamins for several months. Bill paid for by the PLF; the family could never afford it.
The principal who brought the boy to Siem Reap arrived with a raging fever and sweat pouring off of him in sheets. Lori tried to take his temperature and the guy had no idea what to do with a thermometer. He was taken for lab work and then isolated in an empty room at the guest house. Diagnosis: typhoid fever. Treatment: five days of appropriate antibiotics, though the pharmacy only wanted to give him three
days worth. “If he’s from the countryside, that will probably be enough.” The principal was sent back to his village the next day.
Outside of the two children’s hospitals, families line up every day and camp out every night on the sidewalks for immunization clinics and in hopes of getting some medical attention. Some people come for minor things that could be treated closer to home if there was any treatment available in their villages. Some people bring their children too late, having already exhausted all sorts of traditional medicine and possibly losing what few assets they had to pay for a local healer who was unsuccessful. The Angkor Children’s Hospital once had a ten-pound, ten-month-old baby brought in from the countryside by his father and sister. His mother had died of unknown causes and the baby was seriously malnourished. Luckily, this story had a relatively happy ending, but who knows how many times a child in a similar situation would never be seen at a hospital at all.
This hospital also runs a home-visiting service, sending nurses to see patients at home after discharge to provide education and follow-up. Sound familiar? I can’t imagine anything I would
rather do than join up with this team, but I’m probably not much use if I don’t speak Khmer.
Because so many serious diseases in this part of the world involve a hemorrhagic component, there is a constant need for blood donations. Jaz and I went to the (clean and safe) Angkor Children’s Hospital to see if we could help. I’ve been banned by the Red Cross at home for testing false-positive on one of their screening tests, so I was unsure if I could donate. The hospital was willing to take my blood and figure out later whether or not they could use it, but my hematocrit was slightly under their cut-off point, so I couldn’t give at all. Jaz was ready to give blood for the first time, and since the Red Cross allows 17-year-olds to donate at home, I was shocked that this hospital won’t take anyone under 18. (Well, I was shocked until I was reminded that it is run by the Swiss.) Despite our good intentions, we were of no use to them.
So, now what?
How do I figure out how to do something useful in response to all of this? Clearly,
money makes a difference. Vaccinating the orphans at the CDV against hepatitis greatly improves their chance of a longer, healthier life. Setting up a clean water supply and hygiene education and bars of soap for the children at the rural Knar school greatly improves their chances of avoiding more serious infections. Vitamin supplements for these and other children will improve their overall health and avoid pain and suffering and scary hospital experiences.
Have any of us ever had to worry about our children suffering a true vitamin deficiency? Have we ever truly had to worry that they wouldn’t have enough of something as basic as clean water and adequate food? I’ve probably had to worry more about whether my family has
too much of something rather than not enough. “Don’t watch so much TV!" "I've got to stop eating these cookies!" "I think you already have enough video games/Beanie Babies/baseball cards/etc.” "I really shoul "We've got to get rid of all this stuff - we never use it."
What sacrifices am I willing to make? How many movies, how many nice bottles of wine, how much internet speed would I be willing to give up? I don’t really
know the answers yet, and I don’t think that I should give up
everything I love and enjoy, but dollars I will hardly miss can make an actual difference somewhere in Cambodia. I like thinking I might make an actual difference, no matter how small it may seem.
What can you do? How can we all help?
Talk to me, people. Please?
I am only one, but still I am one.
I cannot do everything, but still I can do something.
I will not refuse to do something that I can do.
Sources include:
National Institute of Statistics World Health Organization HartNet US Mortality Rates from WHO Cambodia Mortality rates from WHO New Internationalist Global Issues WHO-UNICEF Joint Statement
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Deb
non-member comment
typo
Life Expectancy in the US......9 years? Maybe you should all move to Cambodia!! he he